Summary On 12 July 2006, an Air Canada Embraer 190-100 (registration C-FHIU, serial number 19000037) was being operated as Flight ACA1156 on a scheduled flight from Edmonton, Alberta, to Toronto, Ontario, with five crew members and 81passengers on board. At 1011 mountain daylight time, the aircraft commenced its take-off. During rotation, the crew noticed that the aircraft pitch response was different than normal. The aircraft successfully climbed away and the flight continued and made an uneventful landing in Toronto. Ce rapport est galement disponible en franais. Other Factual Information History of Flight The flight crew was scheduled for a 10-hour duty day, operating two segments. The first segment, from Toronto/Lester B. Pearson International Airport (CYYZ) to Edmonton International Airport (CYEG), was flown by the captain. A 45-minute turn-around was scheduled, followed by a return to Toronto. On arrival in Edmonton, company maintenance staff had to power down1 the aircraft to clear a secondary power distribution assembly (SPDA) fault message. Because aircraft servicing was to be completed with only battery power available, the captain had to oversee the refuelling operation and supervise the servicing of the lavatory system. The captain completed these tasks, while the first officer was completing the pre-flight walk-around inspection. After the power-down exercise, the SPDA fault message was cleared and the aircraft was declared serviceable. For the return flight to Toronto, the captain was the designated pilot not flying (PNF) while the first officer was the pilot flying (PF). Company standard operating procedures (SOPs) require that the PNF calculate the take-off performance data using an on-board laptop computer commonly referred to as an electronic flight bag (EFB).2 The thrust setting and take off speeds are then to be verified by the PF, copied onto the operational flight plan, and then entered into the flight management system (FMS). After completion of the walk-around, the first officer calculated the preliminary take-off performance data using the captain's laptop. The captain's laptop was used because the first officer's laptop power cord was defective. The captain's laptop had been left plugged in to ensure continued battery charging. However, the first officer had to reach over to the captain's side of the cockpit because the power cord on the captain's side was not long enough to reach to the first officer's side. All preliminary load information was entered. However, an error in the fuel weight was introduced when the first officer entered the weight of the fuel on board (FOB) at the time, which was 3700kg, instead of entering the planned fuel for departure, which was 10200kg The first officer then transcribed the resulting take-off performance data to a blank area at the upper right corner of the operational flight plan (see Appendix A). These data included the take-off weight (TOW), thrust setting, decision speed (V1), rotation speed (Vr), take-off safety speed (V2), flaps up speed (Vfs), and the stabilizer trim position. The transcribed data were 41700kg, 84.9, 137, 137, 140, and 186 with a stabilizer trim of 1.3 UP, respectively. Had the planned FOB weight of 10 200kg been used, the resulting figures would have been 47600kg, 90, 149, 149, 151, 200 and 1.3 UP trim (see Table 1). When the captain returned to the flight deck, he assumed his PNF duties and proceeded to enter the preliminary performance figures into the FMS. Table 1. Performance data * indicates fuel in thousands of kilograms Approximately 15 minutes before departure, the captain was advised that the flight service director (FSD) was not on board. He then contacted the Station Operation Control (STOC) in an attempt to locate the FSD. Shortly thereafter, the FSD arrived. The crew members received their air traffic control (ATC) clearance, and entered the navigational data into the FMS. As part of the pre-flight fuel check, they compared the fuel gauge indication (10.2tons) with the operational flight plan required fuel (10.15tons). They verified that the fuel sheet indicated the proper flight plan revision number, and completed the ACARS3 pre-flight fuel check. The SOPs did not require that they compare the actual FOB with the FOB entry on the laptop computer take-off page. Consequently, no discrepancy was noted. Shortly after initiating the before-start checklist, a flight attendant (FA) advised the flight crew that water was overflowing from a coffee maker. While the first officer communicated with the FA over the interphone to resolve the water overflow problem, the captain was advised by ATC that the departure runway had been changed, and that they would now be departing from Runway 12. Because there had been a problem with the first officer's laptop power cord, the captain completed the changes using his laptop. He entered the new runway, temperature and altimeter setting, and recalculated the take-off performance data. By design, the system automatically transferred the fuel figure that had been initially entered (3700kg), and used this figure for the new calculation. The new performance data generated were then compared to the previously calculated data and, because of the similarities, were accepted as valid. The captain did not identify either the incorrect fuel weight, or the incorrect take-off weight presented on the laptop take-off page. He then entered the new thrust and take-off values into the FMS. When the crew members called ATC for clearance to push back from the gate, they were unable to contact either ground or tower control because those two frequencies were unserviceable. The crew members were eventually able to contact departure control. They received push-back clearance 10 minutes after the scheduled departure time. After engine start and release of the ground support crew, the crew requested, and received, taxi clearance for a departure from Runway 12. During taxi, the crew received, and the first officer reviewed, the final load data on the ACARS. The final load data values were compared to the operational flight plan values listed at the bottom left of the operational flight plan, and accepted, because they were within the prescribed SOP tolerances. At no time were the final load data values compared to the EFB values that had been transcribed to the top right corner of the operational flight plan, nor was this required by SOPs. The first page of the operational flight plan lists the planned block fuel, estimated zero fuel weight and estimated take-off weight at the bottom left corner. A designated area situated immediately right of these figures is used to transcribe the final load data. There is no specific area on that same page to transcribe the performance data calculated on the EFB. Crews normally transcribe these data to the top right corner of the page. At 1011 mountain daylight time,4 the aircraft took off from Runway 12. The aircraft was rotated at a speed of 140 knots, at a rate of 1.5 to 2 degrees per second, in a smooth and continuous motion. The actual lift-off occurred at 159 knots, eight seconds after the first up-elevator input to the flight control. During rotation, the crew noticed that the aircraft pitch response was different than normal. The aircraft felt as if it were out of trim and slow to respond. The aircraft was not equipped with any device that would have provided the crew with an accurate and timely indication of inadequate take-off performance. Presently, there are no such devices certified for installation or use on civil aircraft. In recent years, considerable effort has gone into the development of a reliable means to detect inadequate take-off performance. Transport Canada (TC) created a team to continue to explore ways of building a take-off performance monitoring system using emerging technologies as proof of concept. Once above 10 000feet above sea level (asl), the crew members reviewed the performance data on the EFB and noted the discrepancy. They immediately advised company dispatch. The rest of the flight was uneventful. On arrival in CYYZ, the crew filed an Air Safety Report (ASR), as is required by the company to address safety concerns. Weather The Edmonton International Airport weather recorded at 1000 was as follows: winds 040 true at 10 knots, visibility 15 statute miles (sm), few cloud layers starting at 1800feet above ground level (agl) with a ceiling at 11 000feet, temperature 15C, dewpoint 10C, and altimeter setting 29.75 inches of mercury. Flight Crew The crew for this flight was current and qualified and was experienced in airline operations. The captain had completed his training on the Embraer in April 2005. The first officer had completed training on the Embraer in October 2005. Electronic Flight Bag The Air Canada Embraer fleet is equipped with Class 1 EFB for determining performance calculations. This EFB is a stand-alone computer that does not share connectivity with aircraft systems. The EFB was introduced into line operations when the Embraer aircraft entered service at Air Canada. The EFB is a laptop computer using a Microsoft Windows-based software application called Legato. The application was developed in house by a team of aircraft performance staff and technical pilots of the Air Canada Flight Operations Embraer team, and was approved for operational use by TC. Take-off performance is calculated in Legato on the take-off page. This page was designed with a two-step calculation process to increase awareness of preliminary versus final load figures. The first calculation assumes that the preliminary figures for the upcoming flight are entered using the estimated zero fuel weight (EZFW) and the planned fuel on board (FOB) for the flight. The final calculation is completed when the crew receives the final load data. Standard Operating Procedures The SOPs for the Embraer were developed by a core team of experienced company check and training pilots, mainly from the Air Canada Regional Jet program. They used procedures provided by the aircraft manufacturer, SOPs from other Air Canada fleets, and procedures from other airlines operating the aircraft. As the SOPs were being developed, they were trialed in a simulator for appropriateness. TC monitored the development and ultimately approved the procedures. This was done in accordance with the Canadian Aviation Regulations, specifically Section 725.138 of the Commercial Air Service Standards (CASS) and the associated guidance of Section 745.138. For the EFB, Commercial and Business Aviation Advisory Circular (CBAAC) 231, dated 20 July 2004, was used as guidance. CBAAC 231 is based on Federal Aviation Administration (FAA) Advisory Circular (AC) 120-71A. The Canadian standards and guidance material used for the SOP approval provides direction and advice that is primarily for content. Other Occurrences On 14 October 2004, a Boeing 747 cargo aircraft crashed on take-off from Halifax, Nova Scotia,5 when the crew attempted a take-off with less than the required thrust and lower-than-required take-off rotation speed. All seven crew members suffered fatal injuries. The crew had used the incorrect take-off performance data that had been calculated on the on-board laptop computer using the aircraft weight from the previous take-off. In June 2006, the TSB issued Recommendation A06-07 to TC stating that the Department of Transport, in conjunction with the International Civil Aviation Organization, the Federal Aviation Administration, the European Aviation Safety Agency, and other regulatory organizations, establish a requirement for transport category aircraft to be equipped with a take-off performance monitoring system that would provide flight crews with an accurate and timely indication of inadequate take-off performance. Although the installation of such a system in aircraft would not prevent data insertion errors from happening, it was seen as a physical defence that would assist the crew in identifying take-off performance data errors. Following this recommendation, TC formed a working group with the objective of exploring ways of building a prototype Take-off Performance Monitoring (TOPM) system. On 10 December 2006, a Boeing 747-400 with 563passengers and 15 crew members on board took off from Paris-Orly Airport, France, also using incorrect take-off performance data. Substantial damage occurred to the lower aft fuselage area when the aircraft over-rotated during the take-off. The runway was sufficiently long that the aircraft was able to become airborne and return for a safe landing. In this instance, the crew had used the aircraft zero fuel weight (ZFW) instead of the take-off weight (TOW) to calculate the take-off performance data. Following the Paris-Orly occurrence, France's Bureau d'Enqutes et d'Analyses pour la Scurit de l'Aviation Civile (BEA) organized a working group to study the issue of data insertion errors leading to take-off performance occurrences. The working group will be analyzing data from similar past occurrences. Taking part in this working group will be the Direction Gnrale de l'Aviation Civile (DGAC) of France, airlines and the Laboratory of Applied Anthropology (Ren Descartes University - Paris V). The aim is to gain a better understanding of the cause(s) of this phenomenon in order to issue appropriate safety recommendations to reduce or eliminate this risk. There have been several reported accidents and incidents that demonstrate that crews throughout the airline industry continue to attempt take-offs using incorrect take-off performance references (see Appendix B). In the occurrences identified in this report, the procedural defences that were in place did not function effectively and, on several occasions, this has resulted in substantial aircraft damage and loss of life. The frequency of occurrences shows that the risk of crews using incorrect take-off performance references remains high because the cockpit procedural and technical safety defences to prevent these errors have been either inadequate or absent.